Effectiveness of ESPITO analgesia in enhancing recovery in patients undergoing open radical cystectomy when compared to a contemporaneous cohort receiving standard analgesia: an observational study

OBJECTIVES

Bowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23-40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy.

METHODS

We performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening.

RESULTS

Combined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes.

CONCLUSIONS

ESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.

Is Immediate Radical Cystectomy Necessary for All Patients with Non-Muscle-Invasive Micropapillary Bladder Cancer?

INTRODUCTION

We aim to review the outcomes of micropapillary urothelial carcinoma (MPUC) of the bladder from a single institution. The hypothesis is that non-muscle-invasive (NMI) MPUC may have a heterogeneous prognosis, and detailed pathological analysis may identify patients that could be managed without immediate cystectomy.

PATIENTS AND METHODS

This is a retrospective analysis of patients presenting with MPUC in a primary transurethral resection specimen (n = 40). The pattern of micropapillary (MP) differentiation [surface/non-invasive (sMP) or invasive (iMP)], extent of MP differentiation and lymphovascular invasion (LVI) were correlated with overall survival (OS), recurrence-free survival and upstaging at re-resection.

RESULTS

Sixteen of 40 patients died after a median follow-up of 37 months. Tumour stage was strongly predictive of OS (p < 0.0001). LVI was associated with increased mortality (hazard ratio 12.4, 95% CI: 3.5-44.5, p = 0.0001), higher pathological stage (p = 0.001), lymph node involvement (p = 0.001) and iMP differentiation (p = 0.006). In NMI patients not undergoing cystectomy (n = 17), NMI-sMP compared with NMI-iMP differentiation was associated with an improved OS when compared with iMP (63 vs. 47 months, p = 0.05).

CONCLUSIONS

MPUC is an aggressive variant of urothelial carcinoma (UC). Similar to conventional UC, LVI associated with MPUC is an adverse prognostic indicator. iMP is a morphological marker for LVI. Histopathological reports should distinguish between sMP and iMP differentiation.

MicroRNA in prostate cancer: functional importance and potential as circulating biomarkers

Background

This non-systematic review article aims to summarise the progress made in understanding the functional consequences of microRNA (miRNA) dysregulation in prostate cancer development, and the identification of potential miRNA targets as serum biomarkers for diagnosis or disease stratification.

Results

A number of miRNAs have been shown to influence key cellular processes involved in prostate tumourigenesis, including apoptosis-avoidance, cell proliferation and migration and the androgen signalling pathway. An overlapping group of miRNAs have shown differential expression in the serum of patients with prostate cancer of varying stages compared with unaffected individuals. The majority of studies thus far however, involve small numbers of patients and have shown variable and occasionally conflicting results

Conclusion

MiRNAs show promise as potential circulating biomarkers in prostate cancer, but larger prospective studies are required to validate particular targets and better define their clinical utility.

Delayed Presentation of Small Bowel Injury During Suprapubic Catheterisation

We present a case of small intestine injury resulting from suprapubic catheter insertion. This case is of particular interest for three reasons. Firstly, the presentation of the injury was delayed by three months, until the time of the first catheter exchange. Secondly, the injury was managed conservatively, without surgical exploration. Finally, the injury occurred using a newer, Seldinger-type suprapubic catheter insertion kit.

Scintimammography: the complementary role of Tc-99m sestamibi prone breast imaging for the diagnosis of breast carcinoma

PURPOSE

To evaluate the complementary role of technetium-99m sestamibi scintimammography in improvement of the sensitivity and specificity of mammography in detection of carcinoma of the breast.

MATERIALS AND METHODS

At 5 and 60 minutes after intravenous injection of Tc-99m sestamibi, scintimammograms were obtained in 147 women (age range, 18-73 years; mean age, 47.9 years +/- 10.2 [standard deviation]) with 153 lesions that warranted breast biopsy (102 lesions) or fine-needle aspiration cytologic analysis (51 lesions). There were 113 palpable and 40 nonpalpable lesions. Lesion size on mammograms was 0.8 x 0.6 cm to 15.0 x 11.0 cm (mean, 2.82 cm +/- 1.71 x 2.39 cm +/- 1.56).

RESULTS

Scintimammographic findings were true-positive in 47 biopsy-confirmed carcinomas, true-negative in 91 benign lesions, false-positive in 11 lesions with benign histopathologic findings (fibrocystic disease [n = 8] or fibroadenoma [n = 3]), and false-negative in four lesions of infiltrating ductal carcinoma. The sensitivity of scintimammography was 92.2%; specificity, 89.2%; positive predictive value, 81.0%; and negative predictive value, 95.8%.

CONCLUSION

The authors conclude that scintimammography is a sensitive test that can improve the detection of breast carcinoma.

The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study

OBJECTIVE

To experimentally investigate the effect of cervical extension-compression traction combined with diversified chiropractic manipulation and drop table adjusting in establishing or increasing cervical lordosis.

DESIGN

Blinded, before and after trial with pre- and postlateral cervical radiographic measurement.

SETTING

Primary care private chiropractic clinic in Saugus, MA.

SUBJECTS

A) Control group--convenience sample who had no health care for 10-14 wk, 30 persons. B) Treatment group 1, nonrandomized control trial, 35 persons, whose pre- and postlateral cervical radiographs were taken 10-14 wk apart and whose radiographs clearly depicted C1 through C7. C) Treatment group 2, nonrandomized control trial, 30 persons, whose pre- and postlateral cervical radiographs were taken 10-14 wk apart and whose radiographs clearly depicted C1 through C7.

INTERVENTIONS

Treatment group 1: diversified spinal manipulation, drop table adjustments and cervical extension-compression traction five times per week for 10-14 wk (12 wk +/- 2). Treatment group 2: diversified spinal manipulation and drop table adjustments five times per week for 10-14 wk (12 wk +/- 2).

MAIN OUTCOME MEASURES

Anterior head translation millimeters, C2 to C7 absolute rotation angle, angle of C1 to horizontal (atlas plane angle), five relative rotation angles (C2-3, C3-4, C4-5, C5-6, C6-7) and qualitative classification of lordotic configuration.

RESULTS

No statistically significant changes existed between the pre- and posttests for the control group except in the C6-7 relative rotation angle. In the treatment group 1, statistically significant differences were found in all X-ray markings. Twenty-nine of 35 members have a lordosis after treatment compared to 11 of 35 before treatment. The C2 to C7 angle changed an average 13.2 degrees, C1 to horizontal changed an average 9.8 degrees, the anterior head translation reduced an average of 6.8 mm, the average relative rotation angle changed: C2-3: 3.1, C3-4: 5.5, C4-5: 4.80, C5-6: 2.7 and C6-7: 1.1. In the treatment group 2, no statistically significant changes existed between the pre- and posttests except atlas angulation to horizontal which increased an average of 3.0 degrees.

CONCLUSIONS

A transformation to a lordotic configuration or increase in lordotic configuration occurred and was measured in the majority of treatment group 1 subjects, while no change in the control group and essentially no change in treatment group 2 was measured. Extension-compression traction combined with diversified chiropractic manipulation and drop table adjusting procedures may improve or partially reestablish the cervical lordosis in 10-14 wk of daily care.

Chiropractic biophysics lateral cervical film analysis reliability

OBJECTIVE

To determine the degree to which the geometric line drawings used in Chiropractic Biophysics Technique (CBP) on lateral cervical radiographs are reliable.

DESIGN

A blind, delayed repeated measures design was used. Three examiners were presented radiographs in random order. All identifying marks were removed prior to each examiner's individual marking and measurement. Each examiner was blinded as to how the previous examiners marked and measured the radiographs.

SETTING

Primary care private chiropractic clinic.

PATIENTS

PARTICIPANTS

Sixty-five subject films were provided from the patient records of a primary care private chiropractic clinic. The 65 radiographs qualified for inclusion in the study based on two criteria: C1 through C7 had to be clearly visible, and there had to be no identifying artifacts.

MAIN OUTCOME MEASURES

Anterior head translation in millimeters, atlas plane to horizontal, Ruth Jackson's cervical stress lines, and five relative rotation angles for C2-C3, C3-C4, C4-C5, C5-C6, C6-C7. Inter- and intrareliability of the three examiners were statistically analyzed.

RESULTS

Intraexaminer for a) C1 to horizontal reliability was .98-.99 with confidence intervals of .96-.99, b) absolute rotation angle from C2 to C7 reliability was .82-.95 with confidence intervals of .80-.99, c) anterior head translation [+Sz] reliability was .86-.99, with confidence intervals of .74-.99, d) relative rotation angle reliability ranges were (C2-C3) .99, and (C3-C4) .98-.99, (C4-C5) .88-.99, (C5-C6) .80-.99, and (C6-C7) .94-.98. Interexaminer reliabilities across examiners ranged from a) Winer:.89-.99 and b) Bartko: .72-.96.

CONCLUSIONS

The reliabilities for intra- and interexaminer were all greater than .70, indicating that these measurements in CBP technique would be considered accurate enough to provide measurements for future clinical studies. The data indicated that the C6-C7 relative rotation angle was the least reliable measurement. This might be due to the very small angles found at this level.

Ecological Risk Assessment at The Regional Scale: Ecological Archives A005-001

Ecological risk assessments are used by policy makers and regulatory agencies for balancing and comparing ecological risks associated with environmental hazards. An approach for regional-scale ecological risk assessment is described and demonstrated by modeling environmental risks associated with elevated ozone in a forested region. The demonstration illustrates (1) how a regional-scale risk assessment might be done, (2) the importance of spatial characteristics in considering regional-scale risk, and (3) the necessity of considering terrestrial and aquatic linkages. Generic problems often encountered when doing regional assessments, the foremost of which is the frequent lack of region-specific information and spatial data, are also highlighted. In the demonstration, two levels of elevated ozone and five different at-risk regional features are considered (forest cover, forest edge, forest interior, landscape pattern, and lake water quality). The mechanism for impacts on these features is ozone-induced stress in coniferous trees, patches of which can then be killed by bark beetle attacks. A stochastic spatial model of land-cover change is developed to evaluate the risks or probabilities of significant changes in the selected ecological features as a consequence of these ozone-triggered beetle attacks. Risk to regional water quality of lakes is evaluated by linking the land-cover output from the spatial stochastic model to an empirical water-quality model that is sensitive to land-cover changes within a lake's watershed. The risk analysis shows that those environmental features that are sensitive to the location of coniferous forest (such as forest edge) are at risk of a significant change due to ozone-induced conifer mortality even though overall coniferous forest cover is only slightly affected. The analysis also suggests a high probability of changes in regional water quality of lakes as a consequence of location-specific forest-cover change.

Human platelet thermostable phenol sulfotransferase from blacks and whites: biochemical properties and variations in thermal stability

Phenol sulfotransferase (PST) catalyzes the sulfate conjugation of catecholamines and of phenolic drugs. Human platelet PST exists in at least a thermolabile form (TL PST) and a thermostable form (TS PST). The mean basal level of platelet TS PST activity in samples from American blacks is significantly higher than the basal activity in samples from whites. We carried out the studies reported here to determine whether the higher basal TS PST activity in platelet homogenates from blacks was biochemically similar to the lower basal activity in samples from whites. We also characterized variations in TS PST thermal stability. Platelet TS PST activities in samples from the two groups were almost identical with respect to pH optima, Michaelis-Menten constant values for substrates, and susceptibilities to inhibition by 2,6-dichloro-4-nitrophenol and sodium chloride. Thermolabile and thermostable TS PST were present in samples from both blacks and whites. Thermal stabilities of TS PST in samples from 167 volunteers (104 blacks, 63 whites) were expressed as heated sample-to-control sample ratios. Bimodal frequency distribution histograms of the heated-to-control ratios revealed subgroups of samples with thermolabile TS PST activities from 13.5% of blacks (heated-to-control ratio less than 0.32) and 12.7% of whites (heated-to-control ratio less than 0.27). The mean heated-to-control ratio for thermostable TS PST from blacks was significantly higher than that from whites (0.52 +/- 0.01 vs 0.43 +/- 0.01, respectively, mean +/- SEM; p less than 0.0001). Our studies demonstrated the similarity of biochemical properties of platelet TS PST at the extremes of basal activity. They also showed equivalent subgroups of blacks and whites with thermolabile TS PST. The results are an important initial step toward testing the hypothesis that inheritance may be one factor in the regulation of basal levels of activities and thermal stabilities of platelet TS PST from American blacks.

Inter- and intra-examiner reliability of the upper cervical X-ray marking system: a second look

To determine the degree of reliability (stability over time) for six Pettibon practitioners, the scores resulting from the reading and re-reading of 30 X rays were analyzed using bivariate scattergrams, Pearson Product-moment correlation coefficient estimates and correlated samples t tests. To examine reliability (equivalence over experts) across the practitioners, a repeated measures analysis of variance approach was used. Liberal and conservative reliability coefficients for the upper angle and lower angle were computed. Examination of the data suggest that the reliability (stability over time) for the practitioners is very good. The data on reliability (equivalence over experts) across the practitioners also suggests reliability is very good.

Human pituitary phenol sulfotransferase: biochemical properties and activities of the thermostable and thermolabile forms

Pituitary tissue contains phenol sulfotransferase (PST), the enzyme that catalyzes the sulfate conjugation of monoamine neurotransmitters. We carried out these studies with pituitaries obtained 21.3 +/- 3.0 h postmortem (mean +/- SEM; n = 21) to determine whether the biochemical properties and variations in levels of human pituitary PST activities were similar to those of PST in platelets from control subjects. PST in the human platelet has been studied thoroughly because of the possibility that platelet PST might reflect levels of PST activity in other tissues such as the pituitary and brain. Our results demonstrated 2 forms of the pituitary enzyme that were similar to the thermostable (TS) and thermolabile (TL) forms of platelet PST with regard to assay conditions, pH optima, Km values for multiple substrates, responses to 2,6-dichloro-4-nitrophenol (DCNP), and thermal stability properties. Pituitary samples also were obtained at autopsy 6.3 +/- 0.33 h (mean +/- SEM; n = 3) after death to determine the effects of storage at 4 degrees C on PST activities. After storage for 6-18 h, 83-99.6% of the TS PST activity remained and 44-66.9% of the TL PST activity remained. Pituitary TS PST activity in samples obtained within 12.1 +/- 3.25 h after death was 121.0 +/- 49.1 units/mg protein (mean +/- SEM; n = 7) with a range from 9.7 to 367.6. TL PST activity was 35.6 +/- 11.6 units/mg protein (mean +/- SEM; n = 6) with a range from 6.1 to 80.7. Wide variations of both enzyme activities were also present in 3 pituitary tumor samples.(ABSTRACT TRUNCATED AT 250 WORDS)

Human platelet phenol sulfotransferase: stability of two forms of the enzyme with time and presence of a racial difference

Thermolabile (TL) and thermostable (TS) forms of human platelet phenol sulfotransferase (PST) were measured over various periods of time. TL PST was assayed with dopamine as the substrate and TS PST was measured with phenol and with p-nitrophenol. Levels of TL and TS PST from the same subjects did not change significantly over 1 day, 1 week, 4 weeks, and 8.5 months. Interassay coefficients of variation of PST activities over 3-4 weeks measured in samples from 8-12 subjects with dopamine, phenol and p-nitrophenol were 13.96%, 13.60% and 13.30%, respectively. There was a significant correlation between PST activity measured in the same samples with phenol and with p-nitrophenol (r = 0.946, n = 18, p less than 0.0001). TS PST activity measured with p-nitrophenol was significantly higher (p less than 0.0001) in platelets from 51 black subjects than the level of TS PST in samples from 52 white subjects (0.72 +/- 0.06 vs 0.42 +/- 0.04 units/10(8) platelets, respectively; mean +/- SEM). These results demonstrate the 'stability' of the levels of both forms of the enzyme with time. They also point out the usefulness of a reproducible assay for the detection of a racial difference in the levels of TS PST.

Parathyroid hormone secretion in normal man and in primary hyperparathyroidism: role of histamine H2 receptors

The effect of histamine and histamine H2 receptors on secretion off parathyroid hormone (PTH) was evaluated by 1) adding histamine phosphate (with or without the histamine H2 receptor antagonist, cimetidine) to the medium in in vitro incubation studies with bovine parathyroid tissue, 2) infusing histamine into rats, and 3) infusing the histamine H1 receptor antagonist, diphenhydramine, or cimetidine into normal men and patients with primary hyperparathyroidism. In vitro, histamine (10(-5)-10(-7) M) caused a dose-related significant stimulation of immunoreactive PTH (iPTH) secretion; this was blocked by the simultaneous addition of cimetidine (10(-5) M). Intravenous infusion of histamine significantly increased serum iPTH in rats. In normal man, infusion of diphenhydramine had no effect, but cimetidine (300 or 450 mg) significantly decreased serum iPTH. However, cimetidine had no effect on serum iTh in primary hyperparathyroid patients. The in vitro observations indicate that histamine can stimulate iPTH secretion by a direct effect on the parathyroid cell and that this is probably a specific effect via histamine H2 receptors because the effect was blocked by the H2 receptor antagonist, cimetidine. The observed inhibition of basal PTH concentration by cimetidine induced histamine H2 receptor blockade (but not by H1 blockade) in normal human subjects suggests that endogenous histamine with H2 receptor activation stimulates even basal PTH secretion and may serve as a modulator of PTH secretion in normal man. Loss of this modulating effect of H2 receptors on PTH secretion is a characteristic of primary hyperparathyroidism.

Copper-rich and conventional amalgam restorations after clinical use

The comparison of clinically retrieved conventional and copper-rich amalgam restorations demonstrated that there are at least two distinct types of compounds that form in vivo in amalgam restorations, tin-rich layers on the exposed surface of many amalgams and tin-chlorine and smaller amounts of stannous oxide products in the interior. In the systems rich in copper, corrosion was confined to the surface and a few isolated areas. The relatively small changes found in the systems rich in copper could account for the superior marginal integrity reported for copper-rich amalgams in clinical trials.

Comparative effect of calcium and of the adrenergic system on calcitonin secretion in man

This study evaluated the effects of adrenergic agents on immunoreactive calcitonin (iCT) secretion in normal man, and compared the time course and magnitude of these adrenergic effects with those caused by modifying calcium (Ca) ion concentration. Ca infusion (15 mg Ca++/kg iv in 4 h) significantly increased plasma iCT within 1 h, reaching 140 +/- 8% of baseline at 4 h. EDTA (50 mg/kg iv in 2 h) significantly decreased plasma iCT within 15 min, with nadir value of 53 +/- 4.9% of baseline at 2 h. The beta-adrenergic agonist, isoproterenol, significantly increased plasma iCT with 5 min, reaching 136 +/- 5.9% of baseline at 30 min. The alpha-adrenergic antagonist, phentolamine, significantly increased iCT within 15 min, reaching 132 +/- 8.6% of baseline at 45 min. The beta-adrenergic antagonist, propranolol, significantly suppressed iCT with 15 min, reaching 51.8 +/-6.3% of baseline at 2 h. Therefore, 1) the adrenergic system (without induced change in serum Ca) can modify CT secretion to as great a degree as can change in Ca ion concentration induced by standard Ca and EDTA infusion tests and 2) even basal secretion of CT can be modified by adrenergic influences. These data strongly suggest 1) that the adrenergic system is an effective modifier of CT secretion and 2) that the adrenergic system, as well as Ca ion concentration, may play an improtant physiological role in control of CT secretion in man.